Healthcare Provider Details

I. General information

NPI: 1770856833
Provider Name (Legal Business Name): JOHNNY GURGEN DO PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2012
Last Update Date: 11/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 ROLLING ACRES RD UNIT 203
LADY LAKE FL
32159-5029
US

IV. Provider business mailing address

920 ROLLING ACRES RD UNIT 203
LADY LAKE FL
32159-5029
US

V. Phone/Fax

Practice location:
  • Phone: 352-435-7695
  • Fax: 352-435-7453
Mailing address:
  • Phone: 352-435-7695
  • Fax: 352-435-7453

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: JOHNNY GURGEN
Title or Position: OWNER
Credential:
Phone: 352-435-7695